William Rutherford
PFD Report
Partially Responded
Ref: 2022-0118
Coroner's Concerns (AI summary)
Staffing levels at the care home were below minimum requirements for one-to-one care, and record-keeping standards remained inadequate and inaccurate, despite prior concerns.
View full coroner's concerns
(1) I am concerned that staffing levels were below the minimum requirement on 27 and 28 December 2020. Mr Rutherford was for one to one care and I am concerned that the appropriate number of staff were not available.
(2) I have previously raised concerns regarding the standard of record keeping at Baedling Manor Care Home. I have not received a response to my previous concerns which I repeat again. This is the second death where a resident has died following a fall at Baedling Manor Care Home and I am concerned that the record keeping does not reflect the needs of the residents or accurately record incidents as they occur. ACTION SHOULD BE TAKEN 6 In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 30 July 2021. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons the family of Mr Rutherford and to the Care Quality Commission, and Safe Guarding. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.
4 June 2021 9 Signature Andrew Hetherington HM Senior Coroner for North Northumberland and Acting Senior Coroner for South Northumberland.
(2) I have previously raised concerns regarding the standard of record keeping at Baedling Manor Care Home. I have not received a response to my previous concerns which I repeat again. This is the second death where a resident has died following a fall at Baedling Manor Care Home and I am concerned that the record keeping does not reflect the needs of the residents or accurately record incidents as they occur. ACTION SHOULD BE TAKEN 6 In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 30 July 2021. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons the family of Mr Rutherford and to the Care Quality Commission, and Safe Guarding. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.
4 June 2021 9 Signature Andrew Hetherington HM Senior Coroner for North Northumberland and Acting Senior Coroner for South Northumberland.
Responses
Action Planned
Due to significant failures, the provider is selling the business to an established provider and the home is currently going through transition, with a new management team. Efforts are being made to significantly develop the safe operation of the home during the transition, including reviews, training, audits and revised processes. (AI summary)
Due to significant failures, the provider is selling the business to an established provider and the home is currently going through transition, with a new management team. Efforts are being made to significantly develop the safe operation of the home during the transition, including reviews, training, audits and revised processes. (AI summary)
View full response
Dear Mr Hetherington Re: Baedling Manor Letter of response to the Coroner; Regulation 28 Report to prevent future deaths
With reference to the cases and , please find outlined in this response the measures taken to prevent future deaths. Please note, the response is in summary form due to the circumstances around the current provision, as follows: As of 12th February, Baedling Manor is currently under notification to close due to significant and multiple failures in regulatory activities. As a result, the current provider has taken the view that attempts to make the home safe under the previous management team has proven unsuccessful and therefore has made the decision to sell the business to an established provider. The home is currently going though transition to a new and established provider operator and a new management team has been employed as part of this process with significant support of the incoming provider. It is anticipated that the changeover will complete before the end of August 202. The new team are unable to comment on historical cases, however all efforts are being made to significantly develop the safe operation of the home during the transition, this includes but is not limited to:
Email: admin@alcyone-hcalthcarc.co.uk Company Registration: 71 50325
• Routine access and support from Director of Care of the management support team
• Enhanced leadership and communication amongst the staff team
• Full time, onsite support from experience nominated Individual.
• Responsive and collaborative communication with CQC leads, Northumberland Safeguarding team, Northumberland Contracts team, Northumberland Infection control team, other visiting professionals, families and residents.
• Full review and implementation of new compliance systems and reporting processes
• Full review and implementation of new care planning processes
• Increased face to face training
• Full health and safety audit and associated actions
• Staffing structure review and revised recruitment and induction processes
• Monitored and audited management action plans A realistic timeframe to move the home into a safe and well led establishment is anticipated to be a 3-6 month period. A CQC inspection review is due in December
2021. If you require any further information, please do not hesitate to contact me.
With reference to the cases and , please find outlined in this response the measures taken to prevent future deaths. Please note, the response is in summary form due to the circumstances around the current provision, as follows: As of 12th February, Baedling Manor is currently under notification to close due to significant and multiple failures in regulatory activities. As a result, the current provider has taken the view that attempts to make the home safe under the previous management team has proven unsuccessful and therefore has made the decision to sell the business to an established provider. The home is currently going though transition to a new and established provider operator and a new management team has been employed as part of this process with significant support of the incoming provider. It is anticipated that the changeover will complete before the end of August 202. The new team are unable to comment on historical cases, however all efforts are being made to significantly develop the safe operation of the home during the transition, this includes but is not limited to:
Email: admin@alcyone-hcalthcarc.co.uk Company Registration: 71 50325
• Routine access and support from Director of Care of the management support team
• Enhanced leadership and communication amongst the staff team
• Full time, onsite support from experience nominated Individual.
• Responsive and collaborative communication with CQC leads, Northumberland Safeguarding team, Northumberland Contracts team, Northumberland Infection control team, other visiting professionals, families and residents.
• Full review and implementation of new compliance systems and reporting processes
• Full review and implementation of new care planning processes
• Increased face to face training
• Full health and safety audit and associated actions
• Staffing structure review and revised recruitment and induction processes
• Monitored and audited management action plans A realistic timeframe to move the home into a safe and well led establishment is anticipated to be a 3-6 month period. A CQC inspection review is due in December
2021. If you require any further information, please do not hesitate to contact me.
Sent To
- Baedling Manor Care Home
Response Status
Linked responses
1 of 2
56-Day Deadline
30 Jul 2021
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
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